Pulmonology Flashcards
1
Q
- SOB
- expiratory wheezing
A
asthma
2
Q
- hyperventilation/increased RR
- decrease in peak flow
- hypoxia
- respiratory acidosis
- possible absence of wheezing
A
SEVERE asthma exacerbation
3
Q
if asthma diagnosis is unclear
A
PFT before and after inhaled bronchodilators
4
Q
asthma and reactive airway disease are CONFIRMED with what finding on PFT?
A
INCREASE in FEV1 of greater than 12%
5
Q
ALL patients with SOB should receive the following
A
- oxygen
- continuous oximeter
- CXR
- ABG
6
Q
best INITIAL treatment for asthma exacerbation
A
- inhaled bronchodilator (albuterol); no maximum dose
- steroid bolus (methylprednisolone)
- inhaled ipratropium (ACh receptor antagonist)
- oxygen
- magnesium
7
Q
when should an asthma patient be placed in the ICU?
A
respiratory acidosis with CO2 retention
8
Q
what is the indication for intubation and mechanical ventilation in asthma?
A
PERSISTENT respiratory acidosis
9
Q
best INITIAL treatment for nonacute asthma
A
inhaled bronchodilator (albuterol)
10
Q
if asthma patient is not controlled on inhaled bronchodilator (albuterol)
A
inhaled steroid
11
Q
if patient is STILL not controlled on inhaled bronchodilator (albuterol), and inhaled steroids
A
inhaled long-acting beta agonist (LABA) (salmeterol, or formoterol)
12
Q
alternate long-term controller medications besides inhaled steroids: extrinsic allergies, such as hay fever
A
cromolyn
13
Q
alternate long-term controller medications besides inhaled steroids: atopic disease
A
montelukast
14
Q
alternate long-term controller medications besides inhaled steroids: COPD
A
- tiotropium
- ipratropium
15
Q
alternate long-term controller medications besides inhaled steroids: high IgE levels, no control with cromolyn
A
omalizumab (anti-IgE Ab)
16
Q
last resort for uncontrolled nonacute asthma (if still not controlled on SABA, inhaled steroids, and LABA)
A
PO steroids (many adverse effects)
17
Q
treatment for exercise-induced asthma
A
inhaled bronchodilator BEFORE exercise
18
Q
- long-term smoker
- increasing SOB
- decreasing exercise tolerance
A
COPD
19
Q
treatment for acute exacerbation of COPD
A
- oxygen (NOT TOO MUCH)
- ABG
- CXR
- inhaled albuterol
- inhaled ipratropium
- steroid bolus (methylprednisolone)
20
Q
what should be added in treatment for acute exacerbation of COPD, if fever, sputum, and/or new infiltrate is present on CXR?
A
ceftriaxone and azithromycin for CAP
21
Q
management of COPD with mild respiratory acidosis
A
BiPAP or CPAP
22
Q
COPD physical examination findings
A
- barrel-shaped chest
- clubbing of fingers
- increased AP diameter mf chest
- loud P2 heart sound (pulmonary HTN)
- edema (blood backing up d/t pulmonary HTN)
23
Q
EKG findings in COPD
A
- right axis deviation (RAD)
- right ventricular hypertrophy (RVH)
- right atrial hypertrophy (RAH)
24
Q
CXR findings in COPD
A
- flattening of diaphragm
- elongated heart
- substernal air trapping
25
CBC findings in COPD
- increased hematocrit (sign of chronic hypoxia)
| - microcytic
26
chemistry finding in COPD
increased serum bicarbonate
27
mechanism of right heart enlargement in COPD
hypoxia = capillary constriction in lungs = diffuse vasoconstriction = increased pressure in RV and RA
28
expected PFT results in COPD
- decreased FEV1
- decreased FVC (loss of elastic recoil of lung)
- decreased FEV1/FVC ratio
- increased TLC (d/t air trapping)
- increased residual volume (RV)
- decreased diffusion capacity lung carbon monoxide (DLCO) (destruction of lung interstitium
29
chronic treatment for COPD
- tiotropium/ipratropium
- albuterol
- pneumococcal vaccine
- influenza vaccine
- smoking cessation
- long-term home O2
30
when is home oxygen indicated in COPD?
- pO2 less than 55
| - oxygen saturation less than 88%
31
what lowers mortality in COPD?
- smoking cessation
| - home oxygen
32
- cirrhosis and COPD
| - EARLY AGE (
a-1 antitrypsin deficiency
33
CXR findings in a-1 antitrypsin deficiency
- bullae
- barrel chest
- flat diaphragm
34
blood test findings in a-1 antitrypsin deficiency
- low albumin
- elevated PT (caused by cirrhosis)
- LOW a-1 antitrypsin level
35
treatment for a-1 antitrypsin deficiency
a-1 antitrypsin infusion
36
- anatomic defect of lungs (from infection in childhood)
- profound dilation of bronchi
- chronic resolving and recurring episodes of lung infection
- VERY HIGH volume of sputum
- hemoptysis
- fever
bronchiectasis
37
CXR finding in bronchiectasis
- dilated bronchi with "tram tracking"
38
MOST ACCURATE test for bronchiectasis
HRCT (high-resolution CT of chest)
39
treatment for bronchiectasis
- NO curative treatment
- chest PT
- rotating antibiotics
40
causes of interstitial lung disease (ILD)
- idiopathic
- occupational exposure
- environmental exposure
- medication
41
medications that can cause ILD
- trimethoprim/sulfamethoxazole
| - nitrofurantoin
42
ILD cause = what disease?
asbestos
asbestosis
43
ILD cause = what disease?
glass workers, mining, sandblasting, brickyards
silicosis
44
ILD cause = what disease?
coal worker
coal worker's pneumoconiosis
45
ILD cause = what disease?
cotton
byssinosis
46
ILD cause = what disease?
electronics, ceramics, fluorescent light bulbs
berylliosis
47
ILD cause = what disease?
mercury
pulmonary fibrosis
48
- SOB with dry, nonproductive cough
- chronic hypoxia
- 6 months or more of symptoms
ILD
49
PE findings in ILD
- dry rales
- loud P2 heart sound (sign of pulmonary HTN)
- clubbing
50
CXR finding in ILD
interstitial fibrosis
51
diagnostic tests for ILD
- CXR
- HRCT
- lung biopsy
- PFT
52
PFT findings in ILD
- decreased FEV1
- decreased FVC
- NORMAL FEV1/FVC ratio (equally decreased)
- decreased TLC
- decreased DLCO
53
treatment for ILD
- no specific treatment
54
if biopsy show inflammatory infiltrate in ILD, what is the treatment?
steroid trial
55
ONLY form of ILD that DEFINITELY responds to steroids
berylliosis
56
- bronchiolitis and alveolitis
- more acute than ILD, presents in days to weeks
- cough, rales, and SOB
- fever, malaise, and myalgias (ABSENT in ILD)
bronchiolitis obliterans organizing pneumonia (BOOP)
| aka, cryptogenic organizing pneumonia (COP)
57
CXR finding in BOOP
B/L patchy infiltrates
58
chest CT findings in BOOP
interstitial disease and alveolitis
59
MOST ACCURATE test for BOOP
open lung biopsy
60
treatment for BOOP
steroids
| no response to antibiotics
61
- black, female, less than 40 yoa
- cough, SOB, and fatigue over a few weeks to months
- rales
sarcoidosis
62
best INITIAL test for sarcoidosis
CXR (enlarged lymph nodes, and maybe ILD)
63
MOST ACCURATE test for sarcoidosis
lung or LN biopsy (NONcaseating granulomas)
64
what will BAL show in sarcoidosis?
increased # of helper cells
65
best treatment for sarcoidosis
steroids
66
- SOB, more often in young women
pulmonary hypertension
67
pulmonary HTN can occur 2/2?
- MS
- COPD
- PV
- chronic PE
- ILD
68
PE findings in pulmonary hypertension
- loud P2
- TR
- right ventricular heave
- Raynaud's phenomenon
69
TTE findings in pulmonary hypertension
- RVH
| - enlarged RA
70
EKG finding in pulmonary hypertension
RAD
71
MOST ACCURATE test for pulmonary hypertension
right heart catheterization (Swan-Ganz catheterization) (increased pulmonary artery pressure)
72
treatment for pulmonary hypertension
- bosentan (endothelin inhibitor)
- epoprostenol/treprostinil (prostacyclin analogs = pulmonary vasodilators)
- CCB
- sildenafil
73
- SUDDEN SOB
- CLEAR lungs
- patient with risk factors for DVT: immobility, malignancy, trauma, surgery, hematological abnormalities
pulmonary embolism
74
CXR findings in PE
- MC result is NORMAL
| - MC ABNORMALITY is atelectasis
75
EKG findings in PE
- SINUS TACHYCARDIA
- MC abnormality is nonspecific ST-T wave changes
- RAD/RBBB (uncommon)
76
ABG findings in PE
- hypoxia
- increased A-a gradient
- mild respiratory alkalosis (2/2 hyperventilation)
77
mechanism of right heart strain in PE
severe pressure increase in PA and RV d/t clot
78
standard test to confirm PE
CTA
79
for a V/Q scan to be accurate, the CXR MUST be
NORMAL
| the less normal the CXR, the LESS accurate the V/Q scan
80
if V/Q scan is low-probability, does it exclude PE
NO, 15% still have a PE
81
if V/Q scan is high-probability, does it definitely include PE
NO, 15% don't have a PE
82
sensitivity of LE doppler
70%
83
if D-dimer is negative
PE extremely unlikely
84
MOST ACCURATE test for PE
angiography
85
patient with PE and CONTRAINDICATION to AC, next step in management
IVC filter
86
treatment for PE
- heparin and O2
| - warfarin for AT LEAST 6 MONTHS
87
treatment for PE in HEMODYNAMICALLY UNSTABLE patient (hypotension)
thrombolytics
88
thrombolytics MOA
activate plasminogen to plasmin
89
best INITIAL test for pleural effusion
CXR
90
next step after CXR for pleural effusion
decubitus films with pt lying down
91
MOST ACCURATE test for pleural effusion
thoracentesis
92
pleural effusion: exudate
causes and lab findings
- cancer
- infection
- HIGH protein (> 50% of serum level)
- HIGH LDH (> 60% of serum level)
93
pleural effusion: transudate
causes and lab findings
- CHF
| - LOW protein (
94
treatment for SMALL pleural effusion
- NO treatment needed
| - diuretics can be used, especially for CHF
95
treatment for LARGER pleural effusion, especially from infection (empyema)
chest tube
96
treatment for LARGE, and RECURRENT pleural effusions
pleurodesis
97
treatment if pleurodesis FAILS
decortication (stripping of pleura from lung)
98
- obese patient
- daytime somnolence
- severe snoring
- HTN, HA, ED, fat neck
sleep apnea
99
MCC of sleep apnea (95% of cases)
fatty tissue of neck blocking breathing
100
cause of small % of patients with sleep apnea
central sleep apnea (decreased respiratory drive from CNS)
101
how is sleep apnea diagnosed?
sleep study (polysomnography)
102
definition of MILD sleep apnea
5-20 apneic episodes/hour
103
definition of SEVERE sleep apnea
more than 30 apneic episodes/hour
104
treatment for sleep apnea: OBSTRUCTIVE DISEASE
- weight loss
| - CPAP (continuous positive airway pressure, or BiPAP
105
if initial treatment for sleep apnea: OBSTRUCTIVE DISEASE is not effective
- surgical resection of uvula, palate, and pharynx
106
treatment for sleep apnea: CENTRAL SLEEP APNEA
- avoid alcohol and sedative
- acetazolamide (causes metabolic acidosis = helps drive respiration)
- medroxyprogesterone (central respiratory stimulant)
107
mechanism of acetazolamide
carbonic anhydrase inhibitor
108
- asthmatic patient with WORSENING asthma symptoms
- brown mucous plug production
- recurrent infiltrates
- peripheral eosinophilia
- elevated serum IgE
- central bronchiectasis
allergic bronchopulmonary aspergillosis (ABPA)
109
diagnostic tests for allergic bronchopulmonary aspergillosis (ABPA)
- Aspergillus skin testing
- IgE
- precipitins
- A. fumigatus-specific Ab
110
treatment for allergic bronchopulmonary aspergillosis (ABPA)
ORAL corticosteroids
111
allergic bronchopulmonary aspergillosis (ABPA) treatment in refractory disease if steroids don't work
itraconazole
112
- sudden, SEVERE respiratory failure syndrome
| - diffuse lung injury 2/2 OVERWHELMING systemic injuries
acute respiratory distress syndrome (ARDS)
113
possible ARDS causes
- sepsis
- aspiration of gastric contents
- shock
- infection: pulmonary or systemic
- lung contusion
- trauma
- toxic inhalation
- near drowning
- pancreatitis
- burns
114
CXR finding in ARDS
diffuse patchy infiltrates that become confluent
115
wedge pressure in ARDS
NORMAL
116
pO2/FIO2 ratio in MILD ARDS
201-300
117
pO2/FIO2 ratio in MODERATE ARDS
101-200
118
pO2/FIO2 ratio in SEVERE ARDS
100 OR LESS
119
treatment for ARDS
- ventilator
- positive end expiratory pressure (PEEP) (keep alveoli open)
- prone positioning
- diuretics
- positive inotropes (dobutamine)
- ICU
120
Swan-Ganz (pulmonary artery) catheterization:
HYPOVOLEMIA
- cardiac output
- wedge pressure
- systemic vascular resistance (SVR)
- LOW
- LOW
- HIGH
121
Swan-Ganz (pulmonary artery) catheterization:
CARDIOGENIC SHOCK
- cardiac output
- wedge pressure
- systemic vascular resistance (SVR)
- LOW
- HIGH
- HIGH
122
Swan-Ganz (pulmonary artery) catheterization:
SEPTIC SHOCK
- cardiac output
- wedge pressure
- systemic vascular resistance (SVR)
- HIGH
- LOW
- LOW
123
- fever
- cough
- +/- sputum
- SOB
pneumonia
124
CAP organism
pneumococcus
125
HAP organism
gram-negative bacilli
126
CURB 65
- confusion
- BUN greater than 19
- RR greater than 30
- BP less than 90/60
- age greater than 65
127
best INITIAL diagnostic test for pneumonia
CXR
128
MOST ACCURATE test for pneumonia
sputum gram stain and culture
129
pneumonia with SOB, order
oxygen
130
pneumonia with SOB and/or hypoxia, order
ABG
131
OUTPATIENT treatment for pneumonia
macrolide OR respiratory fluoroquinolone
```
macrolide = azithromycin/clarithromycin
fluoroquinolone = levofloxacin/moxifloxacin
```
132
INPATIENT treatment for pneumonia
- ceftriaxone, AND azithromycin
OR
- fluoroquinolone ONLY
133
treatment for ventilator-associated pneumonia (VAP)
- imipenem/meropenem, piperacillin/tazobactam, or cefepime
AND
- gentamicin
AND
- vancomycin/linezolid
134
does a positive sputum culture mean pneumonia?
NO
135
specific associations for pneumonia:
recent viral syndrome
Staphylococcus
136
specific associations for pneumonia:
alcoholic
Klebsiella
137
specific associations for pneumonia:
GI symptoms, confusion
Legionella
138
specific associations for pneumonia:
young, healthy patient
Mycoplasma
139
specific associations for pneumonia:
birth of animal (placenta)
Coxiella burnetii
140
specific associations for pneumonia:
Arizona construction worker
Coccidioidomycosis
141
specific associations for pneumonia:
HIV with CD4 count less than 200
Pneumocystis jirovecii (PCP)
142
ventilator-associated pneumonia
- fever
- hypoxia
- new infiltrate
- increasing secretions
143
when should steroids be given in PCP pneumonia?
- pO2 less than 70
| - A-a gradient more than 35
144
- risk groups (immigrants, HIV-+ patients, homeless patients, prisoners, alcoholics)
- fever, cough, sputum, weight loss, night sweats
tuberculosis (TB)
145
best INITIAL test for tuberculosis (TB)
CXR
146
test to confirm TB
sputum acid-fast stain and culture
147
treatment for TB
1. isoniazid (INH) x 6 mos
2. rifampin x 6 mos
3. pyrazinamide x 2 mos
4. ethambutol x 2 mos
148
ALL the antituberculosis medications can cause?
hepatotoxicity
149
when should antituberculosis medications be stopped if transaminases become elevated?
reach 5x upper limit of normal
150
adverse effect of isoniazid
peripheral neuropathy
151
adverse effect of rifampin
red/orange-colored bodily secretions
152
adverse effect of pyrazinamide
hyperuricemia
153
adverse effect of ethambutol
optic neuritis
154
which conditions require TB treatment for MORE THAN 6 months
- osteomyelitis
- meningitis
- miliary TB
- cavitary TB
- pregnancy
155
what is a POSITIVE PPD test?
5mm: close contacts, pts on steroids, HIV-positive
10mm: risk groups (immigrants, HIV-+ patients, homeless patients, prisoners, alcoholics, healthcare workers)
15mm: those without increased risk
156
if a patient has NEVER been tested for TB, how should the patient be tested?
2-stage testing
| if FIRST test is NEGATIVE, repeat test in 1-2 WEEKS to confirm
157
what is the indication for IGRA (interferon gamma release assay) (Quantiferon)?
same as PPD
158
what is the lifetime risk for HIV-UNinfected individuals with latent TB infection developing active TB d/t reactivation?
10%
159
what is the lifetime risk for HIV-INFECTED individuals with latent TB infection developing active TB d/t reactivation?
10%/year!
160
if PPD is POSITIVE, next step?
CXR
161
if PPD is positive, and CXR is ABNORMAL, next step?
sputum staining for TB
162
if sputum staining for TB is POSITIVE, next step?
treat with full-dose, 4-drug therapy
163
if PPD is POSITIVE, but CXR is NEGATIVE
isoniazid ALONE for 9 MONTHS
164
once a PPD is POSITIVE, should you repeat it?
NEVER
